Corrine Y. Jurgens

Why do elders delay responding to heart failure symptoms

BACKGROUND Elders with heart failure (HF) are at risk for frequent hospitalizations for symptom management. Repeated admissions are partly related to delay in responding to HF symptoms. Contextual factors such as prior illness experiences and social/emotional factors may affect symptom interpretation and response. The Self-Regulation Model of Illness guided this study as it acknowledges the dynamic nature of illness and influence of contextual factors and social environment on the interpretation and response to symptoms. OBJECTIVE The purpose of this study was to describe contextual factors related to symptom recognition and response among elders hospitalized with decompensated HF. METHODS A mixed-methods design was used. The HF Symptom Perception Scale (physical factors), Specific Activity Scale (functional performance), and Response to Symptoms Questionnaire (cognitive/emotional factors) were administered to participants aged >or=65 years. Symptom duration and clinical details were collected by interview and chart review. Open-ended questions addressing the symptom experience, including the context in which symptoms occurred, were audiotaped, transcribed, analyzed, and compared across cases to inform the quantitative data. RESULTS The convenience sample (n = 77) was 48% female, 85.7% were non-Hispanic White, and mean age was 75.9 years (SD = 7.7 years). Functional performance was low (81% class III/IV). The most frequently reported symptoms were dyspnea, dyspnea on exertion, and fatigue. Median duration of early symptoms of HF decompensation was 5 to 7 days, but dyspnea duration ranged from 30 minutes to 90 days before action was taken. Longer dyspnea duration was associated with higher physical symptom distress (r = .30) and lower anxiety (r = -.31). Sensing and attributing meaning to early symptoms of HF decompensation were problematic. DISCUSSION The physical symptom experience and the cognitive and emotional response to HF symptoms were inadequate for timely care seeking for most of this older aged sample.

Symptom Clusters of Heart Failure

Patients with heart failure (HF) report multiple symptoms. Change in symptoms is an indicator of HF decompensation. Patients have difficulty differentiating HF symptoms from comorbid illness or aging. The study purpose was to identify the number, type, and combination of symptoms in hospitalized HF patients and test relationships with comorbid illness and age. A secondary analysis from a HF registry (N = 687) was conducted. The sample was 51.7% female, mean age 71 +/- 12.5 years. The theory of unpleasant symptoms informed the study regarding the multidimensional nature of symptoms. Factor analysis of nine items from the Minnesota Living with HF Questionnaire resulted in three factors, acute and chronic volume overload and emotional distress. Clusters occurred more frequently in older patients, but caused less impact.

Psychometric testing of the heart failure somatic awareness scale.

Background: Self-management of heart failure relies on patients to assess their symptoms, but their ability to do so is often difficult to determine. The 12-item self-report Heart Failure Somatic Awareness Scale (HFSAS) was developed to measure awareness of and distress secondary to heart failure symptoms. The purpose of this study was to test the psychometric properties of the HFSAS. Methods and Results: Feasibility and discriminant validity of the HFSAS were tested in 49 patients admitted for an exacerbation of heart failure. The HFSAS was acceptable to patients and discriminated between heart failure symptoms and anxiety (r = 0.25, P = .08). When reliability and validity were tested in 201 patients with acute heart failure, theta reliability was adequate (0.71). The HFSAS was low to moderately correlated with general bodily awareness (r = 0.48). No difference was found based on gender, but younger patients had higher mean and median HFSAS scores (more distress). The HFSAS was a significant predictor of symptom duration prior to seeking care for heart failure; higher scores were associated with longer delay before seeking care. Conclusion: The HFSAS is reliable with content, discriminant, and construct validity. Evaluation of its usefulness in teaching patients to monitor daily symptoms is needed.

Length of delay in seeking medical care by patients with heart failure symptoms and the role of symptom-related factors: a narrative review.

The delay in seeking timely medical care by patients with acute coronary syndrome and stroke is well established. Less is known about the delay in patients with heart failure (HF). Reducing the delay in seeking care and the early initiation of treatment is associated with improved outcomes in patients with HF. The purpose of this narrative review was to describe the length of the delay in seeking care for HF symptoms and identify symptom‐related factors that contribute to the delay in seeking medical care.

ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and The Society of Thoracic Surgeons

This document was commissioned to provide a perspective on clinical registries; to identify specific future opportunities for registries to comprise an informatics infrastructure for quality and efficiency measures that are used for accountability; and to propose a model for a future state characterized by an increasingly close inter-relationship between registries and performance measure development. Specifically, this statement focuses on how registries and performance measures are intertwined and how …

Heart failure management in skilled nursing facilities: A scientific statement from the American Heart Association and the Heart Failure Society of America

655 Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age. Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. Transitions between hospitals and SNFs may be problematic. SNF 30-day rehospitalization rates for HF range from 27% to 43%, and long-term care residents sent to the emergency department are at increased risk for hospital admission and death. The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patientcentered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting.

Blunted Responses to Heart Failure Symptoms in Adults With Mild Cognitive Dysfunction

Introduction:Mild cognitive dysfunction is common among adults with heart failure (HF). We hypothesized that mild cognitive dysfunction would be associated with poor HF self-care behaviors, particularly patients’ ability to respond to symptoms. Methods:We analyzed data on 148 participants in an observational study of symptoms in adults with moderate-to-advanced HF. Mild cognitive dysfunction was measured with the Montreal Cognitive Assessment (MoCA; range, 0–30), using cutoff scores for the general population (26) and for adults with cardiovascular disease (24). Heart failure self-care management (evaluation and response to HF symptoms) was measured with the Self-care of HF Index, and consulting behaviors (calling a provider when symptoms occur) were measured using the European HF Self-care Behavior Scale-9. Generalized linear modeling and hierarchical linear modeling were used to quantify the relationship between MoCA cutoff scores and indices of HF self-care. Results:The mean age of the sample was 57 ± 12 years, 61.5% were men, and 58.8% had class III/IV HF; the mean left ventricular ejection fraction was 28% ± 12%. Using MoCA scores of 26 and 24, respectively, 33.1% and 14.2% of the sample had mild cognitive dysfunction. Controlling for common confounders, participants with MoCA scores lower than 26 reported self-care comparable with that of participants with MoCA scores of 26 or higher. Participants with MoCA scores lower than 24, however, reported 21.5% worse self-care management (P = 0.014) and 51% worse consulting behaviors (P < 0.001) compared with participants with MoCA scores of 24 or higher. Conclusions:A disease-specific cutoff for mild cognitive dysfunction reveals marked differences patients’ ability to recognize and respond to HF symptoms when they occur. Adults with HF and mild cognitive dysfunction are a vulnerable patient group in great need of interventions that complement HF self-care.

Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized controlled trial

OBJECTIVE The purpose of this study was to test the efficacy of a tailored motivational interviewing (MI) intervention versus usual care for improving HF self-care behaviors, physical HF symptoms and quality of life. METHODS This is a single-center, randomized controlled trial. Participants were enrolled in the hospital. Immediately after discharge, those in the intervention group received a single home visit and 3-4 follow-up phone calls by a nurse over 90 days. RESULTS A total of 67 participants completed the study (mean age 62±12.8 years), of which 54% were African American, 30% were female, 84% had class III/IV symptoms, and 63% were educated at a high school level or less. There were no differences between the groups in self-care maintenance, self-care confidence, physical HF symptoms, or quality of life at 90 days. CONCLUSION Patients who received the MI intervention had significant and clinically meaningful improvements in HF self-care maintenance over 90 days that exceeded that of usual care. PRACTICE IMPLICATIONS These data support the use of a nurse-led MI intervention for improving HF self-care. Identifying methods to improve HF self-care may lead to improved clinical outcomes.

Changes in prescriptive practices in skin and soft tissue infections associated with the increased occurrence of community acquired methicillin resistant Staphylococcus aureus

BACKGROUND Over 30% of the US population is colonized with methicillin resistant Staphylococcus aureus (MRSA). People within the community, without factors associated with Hospital Acquired (HA) MRSA, present with skin and soft tissue infections (SSTIs). Community Acquired MRSA (CA-MRSA) is resistant to antibiotics typically prescribed for SSTI. Many SSTIs are treated with antibiotics that are ineffective against drug resistant strains. STUDY OBJECTIVES This study examines the incidence of SSTIs associated with CA-MRSA, to determine if an increase in SSTIs is associated with changes in prescribing patterns for MRSA. METHODS A secondary analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) data was used to detect incidence of SSTIs based on ICD-9 coding between the periods of 1997-2002 and 2003-2008. Antibiotic prescribing patterns were examined for treatment. RESULTS Incidence of SSTIs increased by 84.7% from 1997-2002 to 2003-2008. Antibiotics prescribed for methicillin sensitive S. aureus decreased while treatment with MSRA antibiotics increased. CONCLUSION There is an increased incidence of SSTI within the community, suggesting that CA-MRSA may be a contributing factor. Health care providers are recognizing the increased incidence of CAMRSA, and are treating SSTI with appropriate antibiotics.

2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair [‡][1] Nancy M. Albert, PhD, CCNS, CCRN, FAHA[§][2] Paul S. Chan, MD, MSc, FACC[‡][1] Lesley H. Curtis, PhD[‡][1] T. Bruce Ferguson, Jr, MD, FACC[§][2] Gregg C. Fonarow, MD, FACC, FAHA[†][3],[‡][1] Michelle Gurvitz, MD, FACC[§][2] P